PAVINGy� s � /( 5 6 / Pete
Date f Job Address �� e T ax Folio
Legal Description Loi Ste 4/ 7? /`' / /i¢>y/ S i J
Owned / Lessee / Tenant A/ Ac./ie.ze, / Master Permit # 3 411
Owner's Address 7a4 /UF ;T - Phone
Contracting o. , "P
}j Address // �� " -J AI e -74 W
Qualifier / ,ir , C ‘ SS # &' P ne . -.
'v e
State # Municipal # Competency # Ins.Co.
Architect /Engineer i/ /4 Address
Bonding Company / /l/4 Address / /
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANI ROOFIN PAVING FENCE SIGN
WORK DESCRIPTION r IZ.S14/ - Ac C X/S/` • / C / °
`10 I /*io4 -''t `/
Square Ft. 5 3 x-
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR
NOTICE OF COMMENCEMENT).
Application is hereby made to obtain a permit to do work and installation as indicated above, and
on the attached addendum (if applicable). I certify that all work will be performed to meet the
standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regulating construction
authorize the above -named contractor to do the work stated.
Signature of owner and /or Condo President
Date:
Notary as to Owner and /or Condo President
My Commission Expires:
** * * * * * * * * * * * * * * * **
FEES: PERMIT -- 0 , „0 RADON C.C.F.
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Zoning
uildin
Mechanical Plumbing_
Estimated Cost(value)O
t56
iota as to Co
y Commission E
1 0(9%i
Signature of Co
Date: 7 /�e/ P: iin type or stamp name of :`:oi. ry Vuhl:c
' >oniry n wn 7 Produced 1.1
ruber of 1.1). rod
4 a can oath, or
6119 NOT take an oath.
NOTARY 1 541600 TOTAL DUE /
Fire Other
Electrical
Engineering